JUST CULTURE TOOLBOX · The Regulation5 sets out the requirement for an organisation to establish a...

JUST CULTURE

TOOLBOX Co-authored by the ATM Partners for Just Culture:ATCEUC, CANSO, ETF, IFAIMA, IFATCA, IFATSEA

JUST CULTURE TOOLBOX | 1

TABLE OF CONTENTS

1 Foreword 4

2 Introduction to Just Culture and the Toolbox 62.1 Just Culture and its added value to the aviation safety chain 62.2 The spirit of the Just Culture Toolbox 7

3 Definitions and domains of Just Culture 93.1 Definitions 93.2 Domains of Just Culture – an overview 103.2.1 Internal Just Culture (corporate and workforce) 113.2.2 External Just Culture (everything outside the organisation) 12

4 Creating a Just Culture 144.1 Where to start? 144.2 Contents of the Just Culture policy 14

5 Protection 175.1 Protection of data 175.2 Protection of the reporter and the reported 175.3 Legal support 18

6 Human performance 19

7 Education, training and promotion 207.1 Education and training 207.2 Internal promotion 20

8 Just Culture benchmarking with other industries or partners 22

9 Conclusions / afterword 23

Appendix A. ‘Measuring’ the Just Culture climate in your organisation 25

Appendix B. Methodologies for interpreting human/system performance 29

Appendix C. References to Just Culture related documentation and links 32

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LIST OF ABBREVIATIONS

ANS (air navigation services)ATCEUC (Air Traffic Controllers European Unions Coordination)ATM (air traffic management)CISM (critical incident stress management)CANSO (Civil Air Navigation Services Organisation) EASA (European Aviation Safety Agency)ECA (European Cockpit Association)ERA (European Union Agency for Railways)ETF (European Transport Workers’ Federation)FSF (Flight Safety Foundation)ICAO (International Civil Aviation Organization)IFAIMA (International Federation of Aeronautical Information Management Associations)IFATCA (International Federation of Air Traffic Controllers’ Associations)IFATSEA (International Federation of Air Traffic Safety Electronics Associations)LAC (ICAO Legal Advisory Committee)FAIR (Flowchart Analysis of Investigation Results)


The various areas that will be covered in this toolbox are shown pictorially below:

1 FOREWORD

Following decades of innovation in systems, technologies, proce-dures and safety management systems, the improvement of safety in operations in modern day industries relies to a significant extent

on a good safety culture. The role of the human is deservedly getting more and more attention to take advantage of the opportunities for safety improvements.

The single most important part of a good safety culture has been recog-nised as Just Culture. This is an atmosphere of trust where employees feel naturally inspired to call to attention safety risks, even when they themselves may be implicated in the discovery of that safety risk. However it is also clear that unacceptable behaviour will not be tolerated. It is this balance that results in the use of the word “Just”.

This document contains a set of guiding principles for implement-ing a Just Culture. While many documents have been written about Just Culture, very few have actually addressed ‘how’ to achieve one. Achieving a Just Culture in any organisation is complex; it will generally take many years. The six air traffic management (ATM) partners for Just Culture (ATCEUC, CANSO, ETF, IFAIMA, IFATCA and IFATSEA) have developed a toolbox as a set of guiding principles that are universal and not limited to the aviation domain. Representing different actors of the organisational domain (employers, workers, professional staff organisa-tions), it is believed that this guidance could be very valuable.


2 Introduction to Just Culture and the Toolbox

2.1 Just Culture and its added value to the aviation safety chain

Safety management systems and procedures allow us to monitor and improve levels of safety in those industries that we call ‘safety-criti-cal’. These industries rely on constant and constructive information to validate the safety of their systems and procedures; the source of the validation comes from staff input. A Just Culture is absolutely essential to the reporting and feedback of information within safety-critical environ-ments, because staff need to feel encouraged to raise attention to safety risks, even though they themselves may be implicated in the uncovering of that safety risk.

It is understood that individuals, despite their training, expertise, experience, abilities and good will, may face situations where undesir-able outcomes occur as a result of the limits of human performance combined with unwanted and unpredictable systemic influences. Just Culture can therefore be described as an environment in which staff can bring to attention underlying safety risks and issues without fear of repercussions. Individuals will only report errors, particularly where blame or fault may traditionally be attributed, if they are treated fairly and justly. With this data, organisations can investigate safety events that will inevitably happen from time to time, allowing them the oppor-tunity to put in place measures to prevent repeat occurrences.

The clear exception to this is in cases of wilful and/or significantly negligent acts by an individual or group of individuals1. All staff have a responsibility for safety.

In order to encourage staff to participate wholeheartedly in safety reporting, it is essential that not just the compliance aspect is enforced, but also that the culture of open reporting is encouraged in order to get the widest participation and thus the most comprehensive data. The subject is complex, not least of all because it is open to influence by

1 Reg (EU) 376/2014, Article 10

human beings, some in direct control of the industry such as within the structures of an organisation, and others that are not, such as the media.

2.2 The spirit of the Just Culture Toolbox

Scope

The idea for the toolbox came from work surrounding the introduc-tion of EU Regulation 376/2014 on occurrence reporting. Although it is recognised that this regulation is not the first document on Just Culture, it is the current regulatory requirement for EASA-participating states. The implementation of Regulation (EU) 376/2014, particularly article 16, lays the legally binding basis, marking the move from a punitive and ‘blame culture’ to a Just Culture. This toolbox seeks to be in line with and reference existing charters, guidelines, regulations, ICAO annexes, wherever they exist.

It is also recognised that Regulation (EU) 376/2014 only covers part of the Just Culture landscape; for example it does not deal with external Just Culture (media, judiciary, etc.). This toolbox therefore focuses on internal Just Culture, see 3.2.2.

Purpose

This toolbox is targeted at staff and managers within organisations providing air traffic management / air navigation services (ATM/ANS), although Just Culture is fully implementable in other areas of aviation and even other industries. The six ATM partner organisations have worked together to provide this document as an aid to implement-ing Just Culture and fostering a healthy and open reporting culture so that aviation safety can be strengthened. Although not binding, all six organisations have brought their many years of collective wisdom to this document. It is hoped that the information contained within can help foster a strong Just Culture in all of our respective working environ-ments.


3 Definitions and domains of Just Culture

3.1 Definitions

The EU regulation on occurrence reporting defines Just Culture2 as:

‘[…] a culture in which front line operators or other persons are not punished for actions, omissions or decisions taken by them that are commensurate with their experience and training, but in which gross negligence, wilful violations and destructive acts are not tolerated.’

Reason (1997) stresses that a balance must be achieved between a ‘no-blame’ culture and a ‘blame’ culture. The optimum state is the presence of a ‘Just’ culture, i.e.:

‘an atmosphere of trust in which people are encouraged, even rewarded, for providing essential safety-related information - but in which they are also clear about where the line must be drawn between acceptable and unacceptable behaviour.’

According to the European Corporate Just Culture Declaration, staff should be provided with the appropriate environment, tools, training and procedures3.

However, deliberate acts of wilful violation of the system or gross negli-gence will not be tolerated. The term ‘gross negligence’ has, since the drafting of Regulation (EU)376/2014, been felt as problematic by some stakeholders. Article 16.10(b) affords some explanation in this context:

‘Where there has been a manifest, severe and serious disregard of an obvious risk and profound failure of professional responsibility to take such care as is evidently required in the circumstances, causing foresee-able damage to a person or property, or which seriously compromises the level of aviation safety.’

2 EU Reg 376/2014 Art.2 (12)3 European Corporate Just Culture Declaration, 1st October 2015

JUST CULTURE TOOLBOX | 11

The ICAO Safety Management Manual4 describes in similar terminology:

‘Policies that distinguish wilful acts of misconduct from inadvertent errors, providing for an appropriate punitive or non-punitive response, are essential to assure the effective reporting of systemic safety deficiencies. Not only is an “absolute no blame” culture unreasonable, it is not even feasible. While management gains safety information, the system will be ineffective if it interferes with appropriate punitive actions. Conversely, a culture that fails to distinguish unintentional errors/mistakes from acts of wilful misconduct will inhibit the reporting process. If personnel avoid reporting for fear of punishment, management does not gain important safety information.

3.2 Domains of Just Culture – an overview

When we talk about where Just Culture exists and operates, we refer to its domains, of which there are two key ones: internal and external Just Culture.

Influential factors within the structure of an organisation and generally under its influence such as its safety policies and procedures are clas-sified under the corporate part of the internal domain. Added to this is the perception of the working staff, usually at the sharp end of the oper-ations, as one of the most important factors that together determine the status of a Just Culture in an organisation.

Conversely, the maturity and excellence of a Just Culture in any organi-sation will be influenced by many factors, some of those being external. Those entities that are considered external are generally outside the control of the organisation, such as the media, government, judiciary and any audit or inspection bodies.

4 ICAO Safety Management Manual, Doc 9859, AN/474, third edition, 2013

Figure 1. Factors influencing Just Culture inside an organisation can be clas-sified into external and internal domains.

3.2.1 Internal Just Culture (corporate and workforce)

The Regulation5 sets out the requirement for an organisation to establish a Just Culture and to adopt internal rules describing how its principles are guaranteed and maintained in consultation with its staff representatives. This may be achieved through a safety (or Just Culture) policy, corporate procedures, safety reporting mechanisms, or tools and techniques that an organisation deploys to achieve a positive Just Culture (or a good safety reporting culture). Whichever route is taken, the final output of such work will establish these rules and guidelines in an accessible format such as a co-signed declaration between manage-ment and staff representatives, a policy document or other. This will be the foundation of an internal Just Culture.

An internal Just Culture is characterised by the logical sum of the corporate policy and procedures, and the perception by staff that they are treated fairly.

5 Regulation 376/2014 (Article 16)

Just CultureDomains

External Internal

Legislation Judiciary Media Corporate Workforce

PerceptionPromotionProceduresPolicy

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3.2.2 External Just Culture (everything outside the organisation)

External Just Culture is everything relating to Just Culture that is outside the confines of the organisation. These entities are most commonly the judiciary or a State’s legal system, the media (social or otherwise), the government and those bodies that undertake inspections or audits of the organisation.

This domain of Just Culture is more difficult to influence as it does not fall directly under the policies or principles set out by the organisation. An example of this is when an event is taken up by the judicial system. Parties within the organisation lose control of the management of the event. This includes how the media portray the issue.

External factors are important in the success or failure of establish-ing a Just Culture environment. An organisation may wish to influence external Just Culture, for example through education or training programmes for the judiciary and/or media. This may be considered part of the policy or procedures for Just Culture and is expanded in chapter 7. Both internal and external Just Culture domains are ‘connected’ through national or regional cultures.


4 Creating a Just Culture

4.1 Where to start?

The initial step in instituting Just Culture is to build trust between organisational stakeholders. Each stakeholder can have a significant influence in shaping the way that a Just Culture is enacted.

To develop this trust, all relevant stakeholders should be engaged and participate in the creation and implementation of the Just Culture policy. The views of the reporting community are especially important, as they provide the information for safety improvements.

4.2 Contents of the Just Culture policy

A Just Culture policy should contain the goals that are important to the organisation. These are the most important elements of the policy:

WHO• the policy addresses staff at all levels within the organisation.

WHY• they are being addressed

The ATM industry is built on people and the human dimension cannot be overestimated. The organisation wants to be as safe as possible; therefore it needs to foster an atmosphere of trust to encourage reporting (see intentions in ICAO Annex 13). Engagement and adherence to the culture are necessary to ensure that high-level safety objectives are translated into everyday operations.

HOW• the organisation intends to gather information

Procedures for confidential reporting should be established. These shall ensure that information is used in a correct manner e.g. this information is not used to judge individual competence.

• the organisation will treat the information Individuals and organisations should understand in advance how,

when, where and for what purposes the information they provide may be used. This should comply with the relevant regulatory requirements6.

• the organisation will interpret human behaviour The policy should state how and where human behaviour referred to in the Regulation will be dealt with.

• education and training will be given The staff at all levels should be trained and their knowledge main-tained in matters of Just Culture.

• information may be handled externally The policy shall indicate when information is divulged externally (for example for legal reasons, anonymised statistics). Reference should be made to any protection the staff are entitled to.

• feedback on Just Culture is provided Methods and means for gathering and disseminating feedback on the Just Culture should be included in the policy.

6 Including the regulation on data protection (Reg EU 2016/679) and the directive on data protection law enforcement (Directive EU 2016/680)


5 Protection

Protection is key to a successful Just Culture. This includes the protec-tion of: • data • those who report• those who may be referred to in the report.

5.1 Protection of Data

It is important to understand how the organisation protects data. Staff should be consulted about the manner in which the data is being managed and what to expect in the case of an event.

The organisation will need to build processes to handle data, as well as safeguards regarding the processing of data within the organisation.

It should be explained how authorities (e.g. safety investigation bureau, judiciary, national aviation authority etc.) can intervene in an investiga-tion and how they may use the available data.

5.2 Protection of the reporter and the reported

For a Just Culture to be functional, both the reporter and the reported should be protected7.

The processes established to protect the individuals should be developed and maintained in cooperation between management and staff. This is one of the conditions to ensure staff adherence to Just Culture.

The organisation may consult with its competent authority with the aim of building a group of ‘peers’ that can provide support in cases that are submitted for legal investigation. This is the case in some countries

7 Reg EU 376/2014 Article 16.7


and can avoid some situations ending up in courtrooms. The organ-isation should also support the competent authority in ensuring the protection of individuals.

Additionally, the organisation may wish to engage with the body responsible for prosecution on how to integrate expertise to support them in making judgements and how this authority can contribute to safety. It is important to ensure that the judiciary understands that investigations carried out under ICAO Annex 13 cannot be used as evidence to prosecute individuals.

5.3 Legal support

When individuals within the organisation find themselves under the scrutiny of authorities, be it regulatory or judicial, the organisa-tion should provide legal support as required. Legal support should be provided even in those cases where the interpretation of human behaviour led the organisation to believe there was a disregard for an obvious risk or profound failure of professional responsibility.

Should it be found that the behaviour of the individual was, without a doubt, unacceptable, the organisation may understandably decide not to provide any legal support.

6 Human performance

One way to describe the ATM system is the interaction between humans, equipment and procedures. All three aspects should be taken into account to ensure the success of Just Culture.

Assessing human performance is a delicate matter. The reporting system should not be used to identify unwanted individual behaviour. This would have a negative effect on the willingness of people to report.

In the rare cases where there is a call to isolate an individual’s actions, the organisation should perform a systemic analysis of incidents, taking into account all factors, such as culture, systems, procedures and circumstances, which are necessary for the interpretation of human performance.

Where it is necessary to review individual actions, it is essential that the process chosen is accepted by the entire organisation. A one-sided judgement of human performance can have devastating consequences for reporting and safety. The organisation should have processes in place to deal with such situations.

While different methodologies exist to assess human actions, it is important that the chosen one is acceptable to the entire organisation. This depends on many factors, such as culture, regulations, size of the unit, relationship between stakeholders, maturity of the safety manage-ment system, investigation methods and focus etc.


7 Education, training and promotion

It is essential that leaders communicate the principles and applica-tion of Just Culture, as well as the organisation’s commitment to a Just Culture, working at all levels of staff including high-level managers as well as frontline workers. All members of the organisation must under-stand the concept of Just Culture, agree with the principles, and practice them every day.

7.1 Education and training

• Just Culture training should be part of both initial and continuation training for staff. This should encompass the entire process of reporting. This includes the use of language which is not misleading and does not provide opinions or assumptions, but merely states facts.

• Just Culture training should be provided to all staff including managers, supervisors and frontline staff. An outside expert could help to motivate trainees and give credance to the content of the training. Supervisors hold a key role as they deal with individuals immediately after the occurrence.

• Critical incident stress management (CISM) programmes should be put in place. CISM programmes have a positive effect on safety culture by allowing people to deal with incidents more openly, minimising blame and enhancing a Just Culture environment.

• Ad-hoc courses should be developed where needed, i.e. if something relevant happens, if a new applicable regulation comes into force etc.

7.2 Internal promotion

• Just Culture awareness campaigns should provide information to staff at all levels. Promotion may be achieved by advertising in working facilities (e.g. rest areas) and by means of various media (leaflets, apps). Seminars and/or workshops may also be customised for each target group within the organisation. These campaigns

should encourage internal debate for self-analysis of the Just Culture environment by staff members.

• External experts might help validate the message that the organisation is trying to communicate.

• A ‘lesson learning’ forum where staff can debate adverse events and how they could be prevented from happening again may promote the value of a Just Culture. Awards may be given to particular personnel for positive actions to raise awareness and enhance trust.


8 Just Culture benchmarking with other industries or partners

Beyond the aviation domain there are a certain number of safety-criti-cal organisations which maintain or should maintain a commitment to safety.

The sharing of knowledge, best practices and learning from organisa-tions dealing with safety such as railways, maritime sector, health care, nuclear power, etc. will improve the reliability of Just Culture principles.

Such initiatives include:

• The EUROCONTROL and European Union Agency for Railways (ERA) Memorandum of Understanding covering closer cooperation between both agencies to enhance aviation and railway safety by promoting Just Culture joint workshops.

• IFATCA, EUROCONTROL and European Cockpit Association (ECA) prosecutor expert courses aiming to bring aviation closer to the judiciary by providing high quality aviation information and expertise to judicial authorities in the aftermath of accidents or serious incidents.

• The EUROCONTROL Just Culture Repository, containing a collection of relevant global, regional and national rules, regulations, advisory material, policies, commitments and declarations on Just Culture.

• The Flight Safety Foundation (FSF) interaction with ICAO through the newly created Legal Advisory Committee (LAC) trying to encourage ICAO Member States and industry to refer to Just Culture principles especially when dealing with data protection.

9 Conclusions / afterword

Achieving a Just Culture in any organisation is an immensely important part of achieving a good safety culture. It is our duty to ensure safety, the importance of which cannot be overestimated.

The six co-authoring organisations hope that this Toolbox will provide helpful guidance on the journey to establishing a true Just Culture. While the document aims to be a complete guide, many other documents are publicly available and are complementary to this document. We encourage feedback which will enable the Toolbox to be updated as necessary.

As a reminder:• To enact Just Culture, trust needs to be built between all who have a

legitimate and appropriate interest. This is a much larger group than may be initially thought.

• Achieving the ideals of Just Culture will require cooperation and understanding of each other’s views.

• Just Culture serves safety. It is not a means of social control or a disciplinary mechanism.

• Just Culture will be tested. Just Culture will be misinterpreted. Each occasion that it is tested or misinterpreted will have its own unique context and is a learning opportunity for all and can be used to strengthen Just Culture.

• Just Culture is perishable. It requires hard work to be sustained by continued commitment to the ideals and by continued dialogue and information between all stakeholders.


Appendix A. ‘Measuring’ the Just Culture climate in your organisation

A.1. Introduction of a self-assessment tool

A tool has been made available for an assessment of the Just Culture climate in an organisation. The tool consists of a ‘smart’ spreadsheet, containing 16 statements that can be ‘scored’ as to how helpful they are inside the organisation. The tool is based on the analysis that an organisation’s Just Culture climate is influenced by three main factors: the external world (laws, regulations, and practices); the internal corporate structure, policies and procedures of an organisation; and the perception of the people inside the organisation, mostly those working at ‘the sharp end’.

Figure 2. The scoring of a Just Culture climate takes the earlier defined domains into account.

Just CultureDomains

External Internal

Legislation Judiciary Public Media Corporate Workforce

PerceptionPromotionProceduresPolicy


The tool is intended to be used through self-assessment and, when applied correctly, it will provide insights into the status of the organi-sation’s Just Culture climate and where areas for improvement can be found.

A.2. Objective and ‘how to’

The objective of the survey is:

• To help improve Just Culture inside your organisation• Create awareness of subjects that can positively drive Just Culture• Enable intelligent conversation in an organisation• It is a tool to create self-awareness. Your organisation will not be

audited on the answers. • The tool is not intended to create benchmarking or competition

between organisations (or to brag about your results!)• Regulatory authorities are not invited to mandate the use of this

tool to any organisation.

Steps to complete the survey:

• The survey is designed to be answered by only a couple of persons in one organisation.

• The survey is not intended to be filled in by many people, units, etc.• You cannot answer ‘don’t know’. If you do not know the answer, go

and find out.• Do not take the answers in the scoring option too literally. The given

answers in the options are example texts. Apply common sense to the scale related to where you believe your organisation is.

Intended audience and completing the survey:

• Typically, the safety manager would lead the survey and collect the results

• The survey should be filled in by:• One or more managers (e.g. safety manager, operations manager,

technical manager, CEO)• Staff representatives (e.g. unions, guilds, professional associations.)

• Capture demographic data in the case of more than one survey to enable discussion and find out differences of opinion

Options for discussing the outcomes of the survey results:

• The safety manager would typically lead the discussions; however this could be done by another function or person in the organisation

• Outcomes should be discussed between participants and relevant others

• Topics to be discussed could include:• Where significant differences exist between responses.• The actual ‘level’ or ‘score’ • Candidate areas for improvement• Plans to improve in specific areas• Focus should be on those areas with the highest weighting as they

are the most important• Improvement plans could focus on where the most progress can

be gained.

A.3. Example outputs

Fig. 3. Just culture climate survey of: example organisation

An example output of the tool could look like the graphic above. The organisation scores well on the corporate level, probably indicating that the policy is in place and procedures have been defined. However, the organisation is weak on external factors, probably beyond the control of the organisation but nevertheless important for the internal climate,

External3%

Corporate36%

Workforce7%

Potential54%


like an overzealous prosecutor, or lack of advanced regulations. There also seems to be room for a lot of improvement at the workforce level, as the perception of the workforce of an effective Just Culture internal mechanism is quite low.

Another example score could be like the following picture:

Fig. 4. Just culture climate survey of: example organisation

This is where the organisation is enjoying maximum trust (46% is maximum score) by the workforce, however it has not developed internal process and procedures. The influence from the external world is positive, as 13% is the maximum score for this area. There is room for improvement in the corporate area. The table below gives the summary data of the survey, indicating the maximum achievable number of ‘points’ per area.

Just Culture Climate survey results of:

Example organisation

Actual score per domain

Maximum achievable p per domain

Percentage of maximum per domain

External 15 15 100%

Corporate 12 45 27%

Workforce 51 51 100%

Total 78 111 70%

Potential 33 30%

Appendix B. Methodologies for interpreting human/system performance

B.1. Introduction

Various methodologies have been developed over the years to ‘judge’ actions by individuals. As scientific knowledge advanced, people were speaking less and less about ‘human error’ and more and more about ‘systems failures’ or even ‘interpreting human performance variability’ to underscore the notion that people normally will not show up at work with bad intentions. Instead, and this is certainly true in high reliability indus-tries, people are willing to give it their best and take pride in performing at the highest professional level. Incidents, mishaps or accidents most often occur due to multiple failures, procedural misunderstandings, dynamically changing environment and more. The human element must be seen as part of the overall system and therefore part of the overall system design. Any variations in the performance of the system (especially non-nominal) must not be attributed to a shortcoming of the human, but rather the outcome of a design process failing to foresee all possible angles of use and dynamics.

B.2. Reason’s culpability tree

One of the earliest examples is James Reason’s ‘culpability tree’ where one is led through a series of questions on a flow chart to determine the level of culpability of a person in an incident. The tool is now consid-ered outdated but certainly sparked more research into the field and was therefore pioneering. In ‘Managing the Risks of Organizational Accidents’, author James Reason provides a decision tree for deter-mining culpability for unsafe acts. This tool is an adaptation of the tree specifically for adverse events.

B.3. David Marx Outcome Engenuity

Outcome Engenuity is a company founded by David Marx, pioneering some work on ‘where to draw the line’. The “Just Culture Algorithmtm” considers three types of behaviour (human error, at-risk, reckless) with associated actions that try to correct that. Short documents for managers, courses and assessment tool are offered through its website.

External13%

Corporate11%

Workforce46%

Potential30%


B.4. Baines Simmons

Similarly, Baines Simmons specialises in safety culture and Just Culture and has developed models that can be applied in organisations for improvement and support. From its website: “Lying at the heart of an organisation’s Just Culture policy, the FAiR (Flowchart Analysis of Investigation Results) System responds to the challenge of creating an open reporting culture within complex regulated organisations, balancing accountability with the desire for learning and improvement.”

B.5. Hearts & Minds

Developed for Shell Oil, the Hearts & Minds theory is an all-encompass-ing structure and associated training package for creating a good and just safety culture in an organisation. The theory is transparent and well documented and considered to be one of the best, albeit a bit academic, and considered a ‘must-read’ on the subject.

Positive and novel elements of this theory are the importance of the role of the manager and the rewarding of outstanding or exemplary behaviour by people.

B.6. Brüggen & Kools

Available free, this is a tool that considers eight different classes of human behaviour and like the Hearts & Minds theory, stresses the importance of the role of the manager as well as describing positive behaviour. This is where the term ‘interpretation of human behaviour’ is introduced.

The tool can be accessed at www.safetyandjustice.eu and is also available on the SkyBrary website at www.skybrary.aero.

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Appendix C. References to Just Culture related documentation and Links

• Sidney Dekker. Just Culture. Balancing Safety and Accountability. Amazon

• Hearts & Minds available at the Energy Institute

• GAIN [Global Aviation Information network] A Roadmap to a Just Culture. Enhancing the Safety Environment.

• Baines Simmons. FAiR® System (Flowchart Analysis of Investigation Results)

• James Reason. Managing Risks of Organizational Accidents. Amazon.

• James Reason. Human error: models and management.

• Patrick Hudson. A new model for a Just and Fair Culture.

• Patrick Hudson. Safety Culture – Theory and Practice

• EUROCONTROL SkyBrary - Link to Just Culture material

• EUROCONTROL. Establishment of Just Culture principles in ATM safety data reporting and assessment.

• Andreas Mateou. Flying in the Face of Criminalization. The Safety Implications of Prosecuting Aviation Professionals for Accidents

• David Marx. Whack a mole. The price we pay for expecting perfection.

• EUROCONTROL. Just Culture Guidance Material for Interfacing with the Judicial System

• Brüggen & Kools http://safetyandjustice.eu/

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This brochure has received financial support from the European Union

The ATM Partners

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